The present invention relates to a method for reducing fraud in healthcare programs using a smart card that contains identification, security measures, and other information to facilitate the transfer of funds and eliminate fraud in the benefit.
Providers of benefits from private healthcare providers have had concerns wherein individuals could xe2x80x9cdouble dipxe2x80x9d in private healthcare provider programs, or service providers could inadvertently xe2x80x9cdouble billxe2x80x9d or inappropriately bill for services rendered.
In addition, proper service and goods providers for healthcare program have had to wait long periods of time to get paid for their services or goods rendered to the eligible employee. This situation has become tedious and causes benefit costs to be very high, reducing overall benefits available, due to these fraud issues.
A need has long existed for a system, wherein the private healthcare provider advances funds to pay for services of a service or goods provider so that an eligible individual does not have to handle money.
This need has been particularly great for incapacitated individuals, such as those in nursing homes, who are no longer able to handle funds or complicated transactions, to have a system wherein a private healthcare provider benefit can be provided properly to a health care provider or similar benefits provider in a timely manner with payment to the provider.
A need exists for a method to reduce the magnitude of transaction costs involved in reviewing and adjudicating payment requests to a private healthcare provider that would have the effect of reducing the rate of increase of private healthcare provider benefit costs, or enable more benefits to be provided to more people.
A need exists to reduce the traditionally high cost of benefits administration, including the review and adjudication of payment requests which results from benefit service or goods providers having to act as xe2x80x9cbanksxe2x80x9d or xe2x80x9ccredit sourcesxe2x80x9d for individuals eligible for the benefit.
Methods and apparatus exist to attempt to streamline the insurance claim payment process, such as the method disclosed in U.S. Pat. No. 6,163,770. This patent revealed using a digital electrical apparatus to generate output for insurance documentation for a first insurance policy having a first risk and claims while revealing a concurrent second insurance policy for a second risk, wherein the second risk is different from the first. The processor of this method is connected to a memory device for storing and retrieving operations including machine-readable signals in the memory device, to an input device for receiving input data and converting the input data into input electrical data, to a visual display unit for converting output electrical data into output having a visual presentation, to a printer for converting the output electrical data into printed documentation, wherein the processor is programmed to control the apparatus to receive the input data and to produce the output data by steps including: inputting actuarial assumptions defining the first insurance policy; and computing a value of a specific financial attribute of the first insurance policy; the method further including the step of inserting the value of the financial attribute in the first insurance policy and other printed documentation related to the first insurance policy. However, this method did not apply to private healthcare provider programs in a simple and direct manner, as with the present system which was designed to meet these needs.
The present invention provides a method for reducing fraud in healthcare programs.
The method involves registering a service or goods provider with a private healthcare provider and issuing a service provider identification code to that provider. Services and goods of the provider can be registered with the private healthcare provider and claim codes would correspond with each registered service.
The method involves using a smart card, which is issued to an individual eligible for a healthcare program of a private healthcare provider. The smart card is used to determine if the individual is the authorized bearer of the card and if the individual is eligible for benefits from the healthcare program. The card is then used to facilitate three transmissions between the service provider to the private healthcare provider by providing relevant information about proposed goods and services, information about the individual and information about accelerating payment for the program.
More specifically, the invention is a method for reducing fraud in a healthcare program. The method entails registering a service provider with a private healthcare provider and issuing a service provider identification code and registering at least one service or at least one good of the service provider with the private healthcare provider and identifying a claim code for each registered service or registered good. Next, the method continues by issuing a smart card to an individual related to a healthcare program of the private healthcare provider wherein the individual has an individual identification code and the smart card has a smart card identification feature to identify the individual; using the smart card to determine if the individual: is the authorized bearer of the card; and is eligible for benefits from the healthcare program.
The smart card is used to determine if a service provider is preauthorized to provide a registered product or registered service under the healthcare program. In addition the smart card is used to facilitate a first transmission from the service provider to the private healthcare provider. The first transmission includes the service provider identification code, the individual identification code, proposed product information for the individual, and proposed service information for the individual. The first transmission also contains corresponding claim codes for the proposed product, corresponding claim codes for the proposed service, a request to confirm: the individual""s eligibility for benefits under the healthcare program, a validation that the proposed good or service is approved for the individual, the service provider""s eligibility to render services or provide goods under the healthcare program, and a request to participate in an accelerated payment program for the proposed good or the proposed service.
In the method the smart card is used to facilitate a second transmission from the private healthcare provider to the service provider, wherein the second transmission comprises: the individual""s eligibility for benefits under the healthcare program; a validation that the proposed good or proposed service is approved for the individual; a validation of the service provider""s eligibility to render services under the healthcare program; a confirmation that an accelerated payment program is available; and an authorization code to provide the proposed product and/or proposed service.
The smart card is used to facilitate a third transmission from the service provider to the private healthcare provider, wherein the third transmission comprises: a list of claim codes for services rendered; acknowledgement by the individual that information on the product and/or service was provided to the individual; acknowledgement that the product and/or service has been received from the service provider; and a request for accelerated payment by the private healthcare provider to the service provider.